Eyeworld

EW CATARACT 28 July 2015 by Kyle D. MacLean, MD, Liliana Werner, MD, PhD, and Nick Mamalis, MD of treatment intervention required. Given the serious complications that may arise, such as TASS, surgeons should be aware of the risk of using postoperative ointments and tight eye patching in the setting of a clear corneal incision. Case 1 An 86-year-old woman underwent cataract removal and placement of a 3-piece silicone IOL (SoFlex LI 61U, Bausch + Lomb, Bridgewater, N.J.). Immediately after comple- tion of the procedure, the patient received betamethasone sodium phosphate-gentamicin sulfate oph- thalmic ointment and pilocarpine gel, followed by placement of a single eye patch and shield. On the first postoperative day visit, it was noted she had corneal cloudiness and an elevated intraocular pressure (IOP) of 28 mm Hg. A mild anterior chamber inflammatory reaction was also noted. Her elevated IOP was successfully treated with medica- tion, but diffuse corneal edema with folds in Descemet's membrane had developed by her first postoperative week visit. At another appointment the presence of an oily substance was noted in the anterior chamber extending through the pupil and coating the corneal endothelium (Figure 1). The patient's visual acuity was counting fingers. A penetrating keratoplasty (PKP) and IOL explanta- tion/exchange were performed with the new IOL (Surgical P366 PMMA, Bausch + Lomb) placed in the ciliary sulcus. The graft would later fail, and PKP had to be repeated. 1 Case 2 At the same surgery center and with the same surgeon as the first case, a 75-year-old woman underwent cataract removal and placement of the same 3-piece silicone IOL design. Immediately after her procedure she was also given ointment and an eye patch and shield. Her first postoper- ative day examination was unre- markable, aside from a mild anterior chamber inflammatory reaction. Five days later, an oily bubble was observed floating in the anterior chamber (Figure 2). At a subsequent visit the oily substance within the T hese cases represent an uncommon but potentially devastating complication from the use of ointments and eye patching following cataract removal and placement of an intraocular lens (IOL) through a clear corneal incision. 1 Toxic ante- rior segment syndrome (TASS) has been previously reported in patients who were given ophthalmic oint- ment post-surgery and who were found to have an oily substance in the anterior chamber. 2–3 The 2 cases presented here demonstrate the varied presentations after such a complication and the varying degree Two cases of TASS caused by an oily substance in the anterior chamber Kyle Maclean, MD bubble was noted to be attached to the anterior surface of the IOL. The patient's visual acuity was 20/50. An IOL explantation/exchange was per- formed, with the new IOL (SoFlex LI 61U silicone) placed in the capsular bag. During the procedure the ante- rior chamber was washed out. After the second surgery the patient's visual acuity returned to 20/25. 1 Lab analysis and results The corneal button and IOL from case 1 were sent to our laboratory, and the IOL from case 2 was sent to the Bausch + Lomb laboratories. The cornea sent to our lab was received in 10% formalin while the IOL was immersed in balanced salt solution. The IOL sent to the Bausch + Lomb laboratories was in the dry state. The cornea received by our lab was bisected and one half prepared for histopathologic evaluation. Dehy- dration and paraffin embedding were performed, followed by serial sectioning and staining with hema- toxylin and eosin. Each section was examined under a light microscope and photomicrographs were taken. The IOL received by our lab underwent gross examination with photography and light microsco- py. It was then sent to the Electron Microscopy Center, University of South Carolina for analysis with an environmental scanning electron microscope in the dry state. The IOL sent to Bausch + Lomb (case 2) un- derwent gas chromatography-mass spectrometry analysis. Gross examination of the cornea (case 1) revealed a loose endotheli- um detaching from the rest of the corneal tissue. Pathologic examina- tion found the corneal epithelium was thinned and the stroma diffuse- ly thickened with complete absence of the endothelial cell layer. Microscopic evaluation of the IOL we received (case 1) showed an oily substance coating both the anterior and posterior surfaces of the optic (Figure 3). Gas chromatog- raphy-mass spectrometry (GC-MS) performed on the lens from case 2 revealed that the substance found on the lens matched the analysis of the antibiotic/steroid ointment given to the patients immediately after surgery. Comments Penetration of ointments into the anterior chamber was described in 1973 by Fraunfelder and Hanna 4 as the cause of glaucoma or uveitis in 25 patients postoperatively. A study by Scheie et al 5 analyzed the effects of differing amounts of ointment in- jected into the anterior chamber of rabbit eyes. They found that by in- jecting more than 0.1 cc of ointment into the eyes, most would develop an inflammatory reaction, glaucoma, and eventually loss of the globe. In the cases presented here, it appears that the antibiotic/steroid ointment was the cause of the de- velopment of TASS, as suggested by the results of the matching GC-MS analyses results for the substance found on the explanted lenses and the ointment used postoperatively. The antibiotic/steroid ointment used had both mineral oil and white petrolatum listed as non-medicinal ingredients, which are common in ophthalmic ointment preparations. Prognosis appears more optimistic if the oil is contained in a bubble in the anterior chamber, as in case 2. If the oil has spread and covered the corneal endothelium, however, it appears to have a detrimental effect on the cornea. Depending on the amount of dispersion of the substance, treatment may vary from IOL explantation/exchange and anterior chamber washing (case 2) to IOL explantation/exchange and PKP (case 1). Even though smaller, clear cor- neal incisions were employed, tight patching of the eye after ointment application may have resulted in opening or gaping of the wound and allowed ointment entry. It has been demonstrated that the pressure within an eye will fluctuate after surgery, and that the wound from a clear corneal incision demonstrates a dynamic morphology. 6 Even though leaking may not be observed in the immediate postoperative period, in- flow of ocular surface fluid can occur in many patients. 7 Liliana Werner, MD, PhD continued on page 30 Cataract/IOL complications: Moran CPC reports Nick Mamalis, MD

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